1. Case discussion 2015/07/21 PGY 何御彰

2. Chief complaint Dizziness with mild nausea and vomiting for two days

3. Past history 60 F Hypertension (HTN) Paroxysmal atrial fibrillation (PAF)

4. Present illness Symptom Episodic dizziness with mild nausea and vomiting for 2 days It lasted more than 10 minutes and recovered spontaneously Provoking factor  Postural change Aggravating factor  Moving her head (X) Otitis 、 Drainage 、 Tinnitus 、 Aural fullness (X) Blurred vision 、 Slurred speech 、 Weakness (X) Diplopia 、 Dysarthria 、 Dysphagia 、 Weakness (X) Ataxia 、 Headache 、 Photophobia 、 Sonophobia

5. Present illness History (X) Barotrauma 、 Middle ear surgery (X) Recent hyperextension injury to neck (X) Recent viral infection (X) Phenytoin 、 Cisplatin 、 Aminoglycoside

6. Physical examination GCS = E4M6V5 Muscle power = 5 of 5 in all extremities Cranial nerve = Grossly normal without nystagmus Gait = Normal without ataxia Dix-Hallpike maneuver = No nystagmus Finger-Nose-Finger test = Bilaterally normal

7. Electrocardiogram

8. Treatment course Laboratory report WBC/Hb/PLT = 6.64/11.1/225 Cre = 0.5 Na/K = 140/3.7

9. Head CT

10. Brain MRI

11. Treatment course Medication Diphenhydramine 30 mg IF Sodium bicarbonate 49.8 mEq IV She felt better subsequently with less severity

12. Discussion Three-Step examination Horizontal head impulse test of vestibulo-ocular reflex function Observation of nystagmus in different gaze position Prism cross-cover test of ocular alignment Stroke. 2009 Nov;40(11):3504-10

13. Discussion Ann Emerg Med. 2014;64:265-268